If you offer help to a first responder, make sure the suggestion has a good chance at actually being helpful
By Kellie O’Dare, Ph.D., MSW, MPA, 2nd Alarm Project
“911 What’s Your Emergency?”
Caller: “My house… it’s on fire! Everyone says to call this number for help.”
“I’m so sorry to hear that, sir. This must be incredibly difficult for you.
It looks like our first available qualified responder can get to you in 3-4 weeks.”
At a previous job, I worked for a program that, among other vital public health services, provided free screenings for certain types of cancers in high risk and lower SES communities. While I acknowledge the criticality of these screening services, I frequently contemplated the ethics surrounding providing screenings and cancer diagnoses to people who were often uninsured and had no immediate access to health care resources. While safety net programs do exist to provide health care in these situations, all too often people still fell through the cracks. I imagine receiving a diagnosis of cancer is overwhelming… but receiving a cancer diagnosis with no access to treatment and limited resources is devastating and potentially even life-ending. Should we stop screening? Absolutely not. Should we improve access to and quality of needed services? You bet we should.
A similar and equally as concerning scenario is playing out with the mental health of our first responders. First responders, including firefighters, EMS professionals, law enforcement officers, and dispatchers, are more likely to experience undiagnosed and untreated PTSD, mood disorders (depression and anxiety), harmful substance use, and suicidal thoughts/behaviors. More first responders now die by suicide than in line of duty deaths. Combined with stigma surrounding help-seeking behaviors, lack of systematic resource and referral programs, and other barriers to care, first responders do not routinely receive a continuum of evidence-based assessment and treatment services from trained mental health professionals. However, building on their inherent strengths of resiliency, ingenuity, and ability to mobilize and operationalize resources, first responder communities have taken it largely upon themselves to develop strategic approaches to mitigate potential adverse mental health outcomes associated with their jobs. By leveraging evidence-based initiatives such as peer support programs, mental health awareness education, and stigma reduction initiatives, first responders have cracked the code to infusing help and raising awareness among their own ranks.
As educational campaigns, culture change, and peer support initiatives result in more first responders being willing to seek help, we must be prepared to facilitate linkages with them to readily accessible, evidence-based, and proficient mental health providers at the routine, urgent, and crisis levels of care. It is hard to ask for help. It is devastating when you finally have the courage to ask for help, and what you need simply cannot be found. Yes, some of the very characteristics that make our first responders incredible at their jobs also serve as a hindrance to them in reaching out for help. However, for too long, we have waved our fingers and chided them for being “bad at help seeking”, when the help they need and deserve seems to be readily offered up, but in reality, nowhere to be found. Should we stop screening? Absolutely not. Should we improve access to and quality of needed services? You bet we should.
The following list provides a snapshot from my vantage point, of the landscape of barriers to services first responders often encounter once they reach out for help.
1. Deep chasm between first responder culture and mental health providers. Evidence strongly indicates the best predictor of positive treatment outcomes (in any population) is the goodness of fit between the client and the mental health provider. However, misunderstandings, mistrust, stigma, and criticism have created a boundary between first responders and the mental health profession. The following are several quotes from first responders, which illustrate the situation well:
“One of the reasons that first responders refuse mental health services is for fear of being red flagged for firearms, thus losing their jobs and/or firearms.”
“First responders fear being judged by mental health professionals that do not understand what our jobs are like.”
“The mental health field is viewed as being tightly involved with liberal political activism, which has a history of being anti-police.”
“Those that have sought help, viewed it as a waste of time. I sought help after spending a few years in a child sex crime unit. The counselor halted our visit on day one because she could not handle what I was talking about.”
“First responders are not trusting of the mental health industry. The risk of seeking mental health services is considered higher than the risk of poor mental wellness.”
Let me repeat that last one. In many of our first responder communities, the risk of seeking mental health services is considered higher than the risk of poor mental wellness.
2. Provider cultural competency. First responders often report dissatisfaction, mistrust, and discontinue services with counselors who are not familiar with their lifestyle and culture. Providers often terminate services with first responders because they are not experienced in or comfortable in working with the type of trauma these men and women present. Providers are not familiar with first responder culture, nor are they skilled in current evidence-based approaches successful in working with the population. Our data indicates that up to 30% of first responders in our area are experiencing PTSD, compared to 3.5% in the general population. It’s quite likely that many providers have not experienced the breadth and scope of concerns that our first responders are presenting. The chart below illustrates preliminary results of our survey of behavioral health issues first responders. Results indicate much higher prevalence of mental health conditions than in the general population.
In addition, first responders often present differently with certain signs and symptoms of mental health conditions that can be easily overlooked by providers who are not skilled in working with this population. (See below)
3. Provider availability. Much of my area of the country (the Florida Panhandle) is designated as a Health Provider Shortage Area (HPSA) or a “high need geographic HPSA” by the Health Resources & Services Administration (HRSA) for mental health services, even in some of our more urban communities. This means the feds have identified a shortage of mental health providers and facilities in this area. Operationally, this results in extended wait times to see a qualified provider, particularly at higher levels of acuity. For example, one commercial insurance carrier provides a website with a listing of over 40 clinicians, yet the list does not include one provider who is taking new clients, or a psychiatrist that can see someone in less than a month’s wait time. First responders have reported to us that resource listings frequently contain names of providers who no longer accept their insurance, or who are even deceased.
4. Benefit affordability. First responders do not join their profession to get rich. Even with commercial insurance (and paying very high monthly premiums), many first responders report facing high deductibles, co-pays, and out of pocket expenses for mental health services. Insurance companies historically have not offered parity in mental health benefits. First responders often report being forced to endure “step-therapies”, having claims denied or are refused authorization for certain needed services even when ordered by a physician, such as residential or specialty care. In addition, about 70% or more of the Florida panhandle is served by volunteer fire service organizations. These entities often do not provide insurance coverage at all, creating greater gaps in access to services. Many mental health providers no longer accept insurance coverage at all. Paying out of pocket is generally not a feasible option for many first responders and their families.
I am a firm believer that if you raise a problem, you should raise at least one potential solution.
So, what should we do?
If you offer help to a first responder, make sure the suggestion has a good chance at actually being helpful. If you provide a list of resources (digital resource listings, EAP, insurance carriers, hotlines, and the like), vet it first. Call the providers yourself. Ask if they are taking new patients. If so, what is the wait time? Do they have experience in evidence-based approaches with first responders? Are the providers located in the first responders’ area? If not, is telehealth a truly viable alternative? Nothing is worse that needing urgent mental health services and spending days searching for a provider who can see you. It is defeating. Help is not help unless it’s helpful.
Capacity building. I strongly encourage first responder organizations to thoroughly evaluate the accessibility, capacity, wait times, utilization data, proficiency with first responders, and member satisfaction with any providers included in their resource lists. For inpatient and residential levels of care I strongly suggest working with local providers to establish policies and procedures for managing first responders in crisis, including developing MOUs and partnerships with inpatient facilities for specialized intake (and transport if needed) for first responders.
Finding the right mental health provider can often be difficult, overwhelming, and time consuming. I advocate utilizing a Behavioral Health Navigator (BHN) or embedded/integrated clinician model when possible to link members into the best fit services. A BHN is a skilled mental health professional (typically a licensed, masters level provider) who can guide members through and around barriers in the complex mental health system. BHNs improve access to quality behavioral health services through integrated health practices. A BHN can provide an initial evidence-based assessment to a member, and then facilitate linkages to appropriate levels of care within the community. The BHN can also work with the peer support team to vet local area providers to ensure seamless and efficient access to providers is available in routine, urgent, and crisis situations.
Providers who are genuinely interested in effectively working with first responders can invest in CEU opportunities to learn cultural competency and EBPs. Some great programs for clinicians include the FL Firefighters Safety and Health Collaboratives Clinician Awareness Program https://www.floridafirefightersafety.org/mental-wellness/clinician-awareness-program , programs offered by the Medical University of South Carolina http://www.helping-heroes.org/ , and workshops offers through the International Association of Firefighters https://www.iaffrecoverycenter.com/community-education/ In addition, providers interested in learning cutting edge trauma informed EBPs for work with first responders can check out UCF Restores Trauma Management Therapy (TMT) at https://ucfrestores.com/training/tmt-training-program/
While taking CEUs is a great start, we have found the most effective providers are ones who are truly willing to immerse themselves in first responder culture by making station visits, participating in ride alongs, and learning as much about the nuances of each community as they can. Earning trust and establishing rapport can take a long time with first responders, and they typically have a strong thermometer giving an accurate read on someone’s genuineness and goodness of fit.
The success of mental health initiatives for first responders truly lies in strongly connected, well trained and steadfastly supported peer support teams. We have got to do a better job of capacity building for our peer support teams, but also build local systems of care in communities. While peer support is the heart of any resilient responder organization, peer support team members must be able to readily link first responders into accessible, proficient communities of care when needed.
Dr Kellie O’Dare is the founder and co-Director of 2ndalarmproject.org